Provider Demographics
NPI:1336654052
Name:HOOSICK STREET PEDIATRICS, PLLC
Entity Type:Organization
Organization Name:HOOSICK STREET PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-273-3732
Mailing Address - Street 1:333 HOOSICK ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-2042
Mailing Address - Country:US
Mailing Address - Phone:518-273-3732
Mailing Address - Fax:
Practice Address - Street 1:333 HOOSICK ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2042
Practice Address - Country:US
Practice Address - Phone:518-273-3732
Practice Address - Fax:518-273-3732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203943-1261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY110002411003OtherCAPITAL DISTRICT PHYSICIANS' HEALTH PLAN, INC.